Provider Demographics
NPI:1477824894
Name:AMARA, ALICE MUSTAPHA (ACNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:MUSTAPHA
Last Name:AMARA
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2381
Mailing Address - Country:US
Mailing Address - Phone:623-241-6152
Mailing Address - Fax:623-241-6152
Practice Address - Street 1:9250 W THOMAS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3382
Practice Address - Country:US
Practice Address - Phone:623-516-8252
Practice Address - Fax:623-516-8253
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4289363LA2100X
GARN229290363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ687467Medicaid
AZZ71338OtherMEDICARE PTAN